medical_journal_year2.pdf    1   1Dr Namrata Rawal, Consultant Neuropsychiatrist,2 Dr Praswas Thapa, Consultant Neuropsychiatrist,3Dr Yadav Bista, Head of Dept, Department of Neuropsychiatry, Shree Birendra Hospital, Kathmandu, Nepal Abstract Objectives: Psychiatric consequences are very common following RTA. The study is sought to identify the prevalence of psychiatric morbidity (e.g. depressive symptoms, anxiety symptoms and symptoms related to PTSD(Post Traumatic Stress Disorder) following injury sustained victims and psychiatric symptoms. Methods: The 102 (male=83,female=19) patients were interviewed using a questionnaire to collect the socio- demographic data, the Self Rating Questionnaire (SRQ) -Beck Depression Inventory(BDI),Beck Anxiety Inventory(BAI) and the Impact of Event Scale -Revised (IES-R). Patients were prospectively followed up for 1 month. Patients were aged between 20-69 years. The impact of injury was assessed by ISS (Injury Severity Scale) and ABI (Abbreviated injury Scale). Results:The mean age was 33.93 years (range 20-69). Overall, the prevalence rate o of Anxiety symptoms-19.6%, depressive symptoms-21.6% and PTSD symptoms-35.3%. Females had a higher rate of PTSD symptoms 52.6% (n = 10), compared to the males 31.3% (n=26). The majority of those with PTSD (47.2%) were young, 20 - 29 years. symptoms 51% and then anxiety symptoms30.4%. The symptoms gradually reduced in the fourth week to PTSD - 35.3%, depression- 21.6% and anxiety-19.6%. The study also showed higher scales of psychiatric symptoms in major injuries in comparison to minor injuries showing direct correlation of psychiatric morbidity with severity of injury. Conclusion: Psychiatric symptoms are frequent and severe after major injuries and less severe after minor RTA. Psychopathology following injury is a frequent and persistent occurrence. Early information and advice might reduce psychological distress and symptoms. Introduction Motor vehicle accidents therefore are a may occur even in those who have not suffered physical injuries. (1, 2) on stress TS with only a few maj and a n x i e t y. W l and pop some of this vari in this may also to the (3) involving drivers, passengers, pedestrians or cyclist. The term ‘accident’ erroneously suggests that all collisions are random (unpredictable) and accidental (unpreventable). (4) Injury is a disease resulting from an interaction of agent, host and environment. Once a person enters a health system for treatment of an injury, only then it is considered a health problem. (5) Injury now ranks among the leading causes of morbidity and mortality as the primary cause of disease among children in the age group of 5 to 14 years, and the third leading cause among people between the ages of 15 to 29 years in 2000. There is an increasing realization that trauma can have marked and sustained psychological effects. Up to 25% of severely injured patients experience some patients these reactions can be long lasting and have profound adverse effects on quality of life. Those effective treatment can be administered. (6) In Nepal fall from a height accounting for the Address for correspondence: namrata_mahara@yahoo.com 2 accident is the commonest cause males are involved twice as the females which may be because males are being exposed to the risks of accidents. (7) The motor vehicle accidents are the single post traumatic stress disorder (PTSD).(8) Prevalence of PTSD following MVA, ranges from 10% (8) to 46% . (9) In another study by (10) reported that most of accidents in Nepal. However there are few studies related to accidents and injuries. But there are many studies in Western and European countries. In a study it is reported that in Nepal 61.5% of spinal injuries are due to many factors like overcrowded roads, poor conditions of roads etc. (11) Thus the present study is an attempt to identify the prevalence psychiatric consequences that some guidelines may be developed in future for the with other departments. Whiplash injuries commonly occur in road somatic symptoms. (12) These somatic symptoms often accompanied by psychological symptoms such as initial ‘shock’ ‘dazed feeling, anxiety, anger. Depression, libido altered appetite and weight, and in some cases, feeling of helplessness horror, despair and reliving experiences.(13) In severe cases where there has been an accompanying head injury with loss of consciousness, similar disorder may occur but post traumatic stress disorders appear to be less frequent. (14) Personality changes and cognitive impairment may occur following countercoup and penetrating head injuries. (15) Patients with posttraumatic stress disorder experience disabling memories and anxiety related to leading cause of post-traumatic stress disorder since Vietnam War. (16) The primary psychosocial consequences of Motor Vehicle Accidents as beyond PTSD fall into the emerging. First, mood disorders, especially new cases of major depression, are most common co-morbid problem: Second, study it was (17) found that 27.4% of survivors with PTSD had another current co-morbid anxiety disorder. Third, several studies MSE a measure to constitute a psychiatric case .Finally there is travel anxiety and driving reluctance: (18) found that 18.4% had travel anxiety at 1 year post MVA assessment; other (19) reported 18.2%. Methods Patients and Procedures;This prospective cross sectional study includes 102 patients, 83 men and 19 women, mean age 33.9 years (range: 20–69 years), who were admitted at orthopedic department after injury sustained due to RTA. After obtaining informed consent, patients were followed by other instrument to assess the symptoms of anxiety, depression and post traumatic stress disorder. Injury severity was assessed by administering ISS and ABI. Patients were again followed up after 4 weeks and the same scale used for the assessment. The questionnaires ask the patients to estimate their anxi ety by using BAI (Beck Anxiety Inventory) (20) and depression by BDI (Beck Depression Inventory) (21) and HIES (Horowitz’s Impact of Event Scale) (22) to explore the psychological impact of a variety of traumas. The injury severity was assessed with use of ABI (Abbreviated Injury Score). (23) Major injury caused the trauma in 55 patients and minor injury in 47 patients. Most patients had upper secondary level education (n-53); third had primary education (n- 19), fourth had lower secondary education (n-13) and some had a university education (n-2). To compare age groups, patients were divided into 5 groups as shown in table 2. Data about the patients participating in the study were collected and analyzed using SPPS-10 for window. Instruments Semi Structured Performa: Self-designed semi Structured Performa was prepared to obtain the socio- demographic characteristics of the patients. It is used to record patient’s name, age, sex address, education, marital status, occupation, religion, economic status and presenting complaints. BDI (Beck Depression Inventory): This inventory assesses depression for patient’s subjective perception. The subject has to rate according to how he has been feeling during the past two weeks on a 4 point. Scale ranging from 0-3, maximum total score is 63. The total score is categorized into mild, moderate and severe depression. The inventory is considered as a standard scale for measuring severity of the symptoms of depression. The 21 item which are rated on a 4 point scales covers the wider Psychopathology of depression. BAI (Beck Anxiety Inventory): BAI is a 21 item self  3 rated questionnaire that describes common symptoms of anxiety. This scale has a reliability value of 0-92 and a validity that ranges from 82-87 and inventory is considered as a standard instrument to measure anxiety symptoms. Scores have implication for both in measuring severity and assessing changes in symptoms due to intervention. IES (Horowitz’s Impact of Event Scale): IES was originally developed in 1979, later it was used for exploring the psychological impact of a variety of traumas. Although many measures of PTSD symptoms have emerged (24), the IES remains widely used. The IES does not measure the hyper arousal symptoms of PTSD described in DSM-IV (25) Injury Severity Score (ISS): ISS is used to assess abbreviated injury scale which is assigned a value form 1 to 6, with: Minor injury (1) Moderate injury (2) Severe but not threatening (3) Life- threatening but survival likely (4) Critical with uncertain survival (5) Fatal (6) and its value correlates with the risk of mortality. Results 102 patients (83 males and 19 females) were enrolled in study. The mean age was 33.93 years (range 20-69).The majority of RTA patients were male age group between 20-29(49.4% n=41) and female age group between 30-39 ( 38.8% n=7). Most of the participants were married (64.7% n = 66), Hindu by religion (88.8% n=90) and of secondary level educated (34.3% n=35). The majority of them were service holder (24.55 n=25) and from middle socio economic status (68.6% n=70). Table 1: Above shows the prevalence of anxiety, depression and PTSD in 1 st and 4th week of patients of RTA. The anxiety symptoms in 1st and 4th st and 4th Duration Anxiety symptoms 2 Yes (%) No (%) 1st week 31(30.4) 71(69.6) P=0.075 4th week 20(19.6) 82(80.4) Duration Depressive Symptoms 2 Yes (%) No (%) 1st week 52(51.0) 50(49.0) P=0.000014th week 22(21.6) 80(78.4) Duration PTSD Symptoms Yes (%) No (%) 2 1st week 95(93.1) 7(6.9) P=0.0000 4th week 36(35.3) 66(64.7) 4 Age (years) Anxiety Symptoms p-valueFirst Week Fourth week No (%) Yes (%) No (%) Yes (%) 20-29 30(63.9) 17(36.1) 38(80.9) 9(19.1) P=0.065 30-39 18(78.2) 5(21.8) 20(86.9) 3(13.1) P=0.699 40-49 16(76.3) 5(23.7) 16(76.1) 5(23.9) P=1 50-59 5(62.5) 3(37.5) 6(75.0) 2(25.0) P=1 60-69 2(66.7) 1(33.3) 2(66.7) 1(33.3) P=1 Total 71(69.6) 31(30.4) 82(80.4) 20(19.6) p-valueAge (yrs) Depressive Symptoms 20-29 19(40.5) 28(59.50) 32(68.1) 15(31.9) 30-39 14(60.8) 9(39.2) 21(91.3) 2(8.7) P=0.007 40-49 13(61.9) 8(38.1) 18(85.7) 3(14.3) P=0.038 50-59 2(25.0) 6(75.0) 6(75.0) 2(25.0) P=0.16 60-69 2(66.7) 1(33.7) 3(100) - P=0.132 Total 50(49.0) 52(51.0) 80(78.4) 22(21.6) P=1.0 PTSD Symptoms p- value Age (yrs) No (%) Yes (%) No (%) Yes (%) 20-29 4(8.5) 43(91.50 30(63.8) 17(36.2) P=0.000001 30-39 1(4.3) 22(95.7) 16(69.6) 7(30.4) P=0.00002 40-49 1(4.7) 20(95.2) 13(61.9) 8(38.1) P=0.0003 50-59 1(1.5) 7(87.5) 5(62.5) 3(37.5) P=0.119 60-69 - 3(100) 2(66.7) 1(33.3) P=0.40 Total 7(6.9) 95(93.1) 66(64.7) 36(35.3)  5 Table 2: st and 4th week. The PTSD symptoms in few of age group in 1 st and 4th 20-29years (p=0.000001), 30-39years (p=0.00002) and 40-49years (p=0.0003). Table 3 Table 3: 0.014 respectively) in 1st week but however in 4th minor and major injury (p=0.018 and p=0.013 respectively). Using the ISS patients of minor injuries were 47(male=38, female=9) and major injuries were 55 (male=45, female=10). Using BAI, the prevalence of anxiety in 4th week 20 (19.6%) was found among the patients enrolled in the study. The age of 20-29 years had maximum anxiety symptoms (19.1% n=9) and female (47.4% n=9) were affected more than male (26.5% n=22).According to severity of injury anxiety predominant in major injury patients (29% n=16) in comparison to minor injury patients (8.5% n=4). Likewise the prevalence for depression was found to be 22 (21.6%) in 4 th week. The age group affected more was 20-29 (31.9% n=15) and sex affected more was female (47.4% n=9) than male (51.8% n=43). Depression was found more with major injury (30.9% n=17) and less with minor injury (10.65 n=5). An overall prevalence of 35.3% (n=36) PTSD was found in 4th week among the patients interviewed. The rate was higher among the females: 10 patients (52.6%) met the diagnostic criteria used compared to 26 more common among the middle aged patients. The majority, (38.1%) of the MVA survivors were in the age group 40 -49 years. The results regarding injury severity was like anxiety and depression, the major injury having higher rates of PTDS symptoms (41.8% n=23) than minor (27.75 n=13). Discussion general population in that they were mostly young. The predominance of males in the sample could be easily explained. Perhaps they were more likely to be motor vehicle drivers and hence more prone to injury compared to the females. There were greater representation of married 64.7% and unmarried were 32.4%.The representation of unmarried were higher in males 36.1% than females 15.8% Marriage was identified as a possible risk factor especially females, 78.9% and for the males (64.7%) of RTA patients. Though these factors were associated with a greater risk and are similar to those of other studies on traumatic events other than motor vehicle accidents (26) they were not statistically professionals and students had higher rates of a c c i d e n t s and developing psychological symptoms. An explanation for this could be that the groups more affected had greater understanding of the possible consequences of the accident and feared that their life goals and ambitions could be adversely affected. The present study has several limitations. First, despite the fact that average number of patients Symptoms distribution with Injury Score in First Week Symptoms Minor Injury Major Injury P value No. (%) No. (%) Anxiety 7(14.9) 24(43.6) P=0.002 Depression 23(48.9) 29(52.7) P=0.703 PTSD 47(100) 48(87.3) P=0.014 Symptoms distribution with Injury Score in Fourth Week Symptoms Minor Injury Major Injury P value No. (%) No. (%) Anxiety 4 (8.5) 16 (29.0) P=0.018 Depression 5(10.5) 17(30.9) P=0.013 PTSD 13(27.7) 23(41.8) P=0.136 6 participated in this study but there is no long-term follow-up, the decrease of post-traumatic stress during the study is a promising result. With regard to future research, it would be useful to investigate study population with a long time follow-up. Anxiety symptoms The study showed that the anxiety symptoms seen higher in major than in minor injury and it was that the anxiety symptoms were seen higher in females than in males. The anxiety symptoms in major injury (p=0.012), this may be perhaps due to vulnerability of females to any stress. Depressive Symptoms The study found depressive symptoms in 51.0% 20.5%. This study was similar to other Studies, O’ Donnell et al, 2004 showed the rates of depression following injury ranges from 5-23%. The present study found that depression was higher in age group 20-29 years and 30-39 years in 1st and 4th The depressive symptoms in male and female differ th week (p=1). PTSD Symptoms In this y were ogy in to We did not use a interview on identifying xi It is their T be an for the of PTSD this group. Prevalence of PTSD (35.3%) is comparable to that found in the developed countries: range 7 - 39%. As in the other studies (27) the females were at a greater risk of developing PTSD. Among those who developed PTSD, 38.1% were in the age group 40-49 years. It appears therefore that the middle aged subjects are more prone to developing PTSD than the younger and older subjects. It is possible that the older subjects had learned coping mechanisms from past experience and younger has enhance their ability to cope with new traumas .(28)Not only has it been shown that higher age could imply a higher risk of developing post-traumatic stress symptoms,(29) but at the same time it also has been reported that no difference concerning post- traumatic stress measured with the instrument IES could be found between younger, older and middle- aged individuals. of patients with PTSD none had been previously diagnosed. All were attending the clinics purely for their physical injuries. Other studies of post-traumatic stress among individuals in different age groups have shown different results. In the present study, the IES was used to assess post- traumatic stress. This instrument has been used in previous studies of post-traumatic stress in vehicle related accidents mostly in whiplash injuries (31,32,33) The levels of post-traumatic stress with 102 patients suffering from moderate to severe stress symptoms in 4th week 35.3% which were clearly higher than previously reported early after injury (13%). (34) Several workers (35, 36) have noted, in particular, that pre-existing major depressive disorder (MDD) developing PTSD. In the present study since the pre-existing psychiatric illness were not excluded, so which could be associated to be of greater risk of developing PTSD. In general those who had suffered psychiatric illness in the past had a greater risk of developing PTSD. Similarly those who had other physical illnesses were at a greater risk. Perhaps the accident acted as a further stressor to these individuals who were already overwhelmed. Conclusion The majority of MVA survivors do develop to identify those at risk. A multidisciplinary approach is therefore essential in the management of the RTA survivors at the orthopedic and trauma clinics if their physical and psychological needs are to be adequately addressed. of all the y out- after vehicle in the that will con- the of a very large public l l Despite these the high levels ology in the month following that y and Co-occur following a physical y Health care systems targeted at have a sibility to an ly and for early atric v accidents by implementing road safety measures such as safety belts, speed limit, improved road infrastructure and strict law enforcement measures on MVA and therefore PTSD and other psychiatric problems.  7 References 1. O’Brien, L. S. Traumatic Events and Mental Health. University Press: Cambridge, 1998. 2. Blanchard EB, Hickling EJ, Taylor AE and Ross W R. Psychiatric morbidity associated with motor vehicle accidents. J. Nervous and Mental Disorder 1995; 183:495-504. 3. 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